The breast and the Thyroid

From Primary Surgery

21 The breast and the thyroid

21.1 Introduction

The breast and the thyroid may both be afflicted by a variety of benign and malignant swellings which need surgery. Both may have abscesses which need draining, the breast often, and the thyroid only rarely. We describe a simple and a modified radical mastectomy, but we do not tell you how to remove the thyroid, because this requires a knowledge of anatomy and an expertise that you are unlikely to have. You will see two kinds of inflammatory lesion in the breast: (1) Acute abscesses, which almost always occur during lactation, but may occasionally occur during pregnancy, and rarely at other times. They are here, rather than with the other abscesses earlier in the book, so that they can be discussed with other 'lumps in the breast'. And, (2) a varied group of subacute or chronic infections, which you will have to distinguish from tumours and tuberculosis of the breast (21.3). THE BREAST 21.2 Pus in the breast The importance of a breast abscess is less for a mother than for her child, who may cease to be breast-fed as a result of it, and be subject to all the hazards of being bottle-fed, particularly marasmus. So your main objective must be to see that when you have treated her abscess, she continues to breast-feed. Acute septic breast infections usually occur during the second week of the puerperium, in a breast which is either engorged, or has a cracked nipple. Antibiotics alone are only effective ifyou give them early, during the phase of acute cellulitis. As soon as there is a definite lump, incise it. Avoid these common mistakes: (1) Don't delay incision, and don't continue with antibiotics alone after an abscess has formed. The mass may fail to resolve, and become so hard (an 'antibioma') that you cannot distinguish it from carcinoma. (2) Don't wait for fluctuation, or for the abscess to point. If you do, she will suffer much unnecessary breast destruction. (3) Provided that she does not present so late that breast-feeding is impossible, don't take her baby away from her breast. He is much the best way of keeping it drained. (4) Don't suppress lactation with stilboestrol, its effects are temporary anyway. Finally, (5) don't forget to insert a drain. Subacute or chronic recurrent abscesses are unrelated to lactation, and are less painful. They are usually close to the areola, are often associated with inversion of the nipple, and they commonly involve both breasts, either simultaneously, or one after the other. Often, a fistula of a mammary duct is present. If the lesion is localized, you can excise it, as in Fig. 21-1. BREAST INFECTIONS For the general method, see Section 5.2. ANAESTH ESIA, Give the patient a general anaesthetic. If you use local anaesthesia, which is not very satisfactory, be sure to premedicate her well with pethidine. ABSCESSES IN LACTATING BREASTS INDICATIONS FOR INCISION, (1) An area of tense induration. You will feel this most easily when her breast is empty. (2) Pain which is severe enough to have kept her awake the previous night. Use the tip of your finger to feel for the point of maximum tenderness. Run your finger firmly across the oedematous swelling: you may feel that its centre is slightly softer than its edges. If you are in doubt aspirate it with a needle (5.1). CAUTION! Don't wait for fluctuation. BREAST A ABSCESSES AND FISTULA B Fig. 21•1 A BREAST ABSCESS AND A FISTULA. A, ifan abscess points at the areola, or near it, make a circumferential skin incision at its margin. Elsewhere in the breast, a circumferential incision is preferable to a radial one, which leaves an uglier scar. B, insert your finger and break down all loculi. C, loosely pack the cavity. D, the cavity has extended below the incision, so a dependant drain has been inserted. E, and F, excising a fistula ofa mammary duct. Both ends ofthe fistula are being excised, including 2 cm of skin distal to the distal opening. After Rob C and Smith R, (Operative Surgery'; (2nd edn), p. 289. Butterworth, with kind permission. INCISING A BREAST ABSCESS 8 Fig. 21-2 DRAINING A BREAST ABSCESS. This is a less schematic figure than the last one. Ifthe pus could have been reached through a circumareolar incision, it would have left a much better scar! Adapted from an unknown source. INCISION. If an abscess points at the areola, or near it, make a circumferential skin incision at its margin. Elsewhere in the breast, a circumferential incision is preferable to a radial one, which leaves an uglier scar. If you are going to get a finger into an abscess, it will have to be at least 2 cm. Cut through the skin and subcutaneous tissue. Push a long haemostat into the abscess, and open its jaws. Pus will ooze out. Feel every part of her breast against the haemostat, and try to enter all its loculi. Remove the haemostat, and use your gloved finger to break down any septa between its loculi. If it is in her subcutaneous tissue, feel for a deeper extension. Insert a drain, and apply a dry dressing. If you wish, you can pack a small cavity; but if you pack a large one, the bulk of the dressings may interfere with breast feeding. If she has a large abscess in a lower quadrant, make a single incision in the lower part of her breast. There is no need to make a main incision, and then another counter incision inferiorly to provide free drainage. If you cannot find any pus, the lesion may be an anaplastic carcinoma, so send a biopsy for examination. If milk flows from the wound, reassure her that it will stop, provided breast-feeding is re-established. CAUTION! (1) If she has no fever, or throbbing pain, consider the possibility of a carcinoma. (2) Follow her up carefully. Another abscess may form. BREAST-FEEDING must not stop! Let her baby continue to suck from her normal breast and, as soon as possible, from her injected breast. But don't let him suck from the infected breast if: (1) Its nipple is cracked. (2) Pus comes from it. If so, express her milk, by hand or with a breast pump. Discard it if it is obviously mixed with pus, otherwise feed it to him. As soon as he can fix on to the nipple, encourage him to suck from it. If she presents late, when breast feeding has become impossible, incise and drain her breast, and give her an antibiotic to hasten the resolution of the inflammatory oedema. Start expressing her breast as soon as possible, and don't discharge her until breast-feeding has been re-established. SUBACUTE AND CHRONIC ABSCESSES. Be sure to take a biopsy for tuberculosis. If: (1) she has a small opening discharging pus, at or near the areolar margin, or (2) recurrent abscesses continue to reappear at the same site, near her areola, she has a mammary fistula (sinus). Examine her during an quiescent phase. See if you can pass a probe from the site of the abscess, through to her nipple. If you can, a fistula is present and you may be able to excise the whole lesion, as in E, and F, Fig. 21-1. Make the incision round the fistulous track, and continue it 2 cm distal to the fistula. There is no need to remove more than 0.5 cm of skin on either side of the track. Deepen the incision to expose the underlying tissue, and excise the fistula. Be sure to excise the central part of the duct, because if you leave it behind, the lesion is sure to recur. RE-ESTABLISH BREAST-FEEDING IN AN INFECTED BREAST 21.3 Lumps in the breast A normal breast is slightly and uniformly nodular; most of its diseases make it lumpy. Sorting out these lumps can be difficult. The important decision is whether or not a patient has carcinoma. Consider all lumps in the breast as malignant, unless you are sure they are benign. No woman should be left with a lump in her breast, if she can have it removed by aspirating a cyst, or by excision. After the menopause lumps in the breast are more likely to be malignant. BREAST LUMPS AND OTHER BREAST DISEASES EXAMINATION HISTORY. How long has the patient had her symptoms? Has she any pain? Is it associated with her periods? If she has pain, is it in one breast or both? Is there any discharge from her nipple? Is it watery, bloody, or like thin pus? EXAMINATION. First examine her sitting up undressed to the waist, then lying down. Examine both her breasts, her liver, and her skeleton. // B Fig. 21-3 TWO FUNGATING TUMOURS OF THE BREAST. Unfortunately, many patients in the developing world present late when their tumours are already fungating like this. A, a fibroadenoma (uncommon). B, a fungating carcinoma (very common); note the 'peau d'orange' ('orange skin') appearance of the skin over the breast, and the malignant ulcer. • Inspect: (1) Her nipples for position, retraction, and cracking. (2) Her areolae for pigmentation, swelling of Montgomery's tubercles, and a rash. (3) Her skin for prominent veins, sinuses, ulcers, and 'peau d'orange'. Palpate her breasts: (1) Start with the breast she considers normal, feel each of its 4 quadrants with the flat of your hand, and then its subareolar area. (2) Feel for lumps, note their size and site, and whether they are single or multiple; also their consistency, warmth, tenderness, mobility, and surface. (3) If you find a lump, feel if it is tethered to the skin, or to pectoralis major. Test for the latter by asking her to place her open hand on her waist, and then ask her to press downwards to tense this muscle, while you try to move the lump. (4) Feel with your finger and thumb behind each nipple, and look for any discharge. (4) Feel her axillary nodes-medial (pectoral), lateral, anterior and posterior. Note their number and size, and if they are fixed to her skin, or to deep structures. A normal breast is slightly and uniformly nodular, especially before the menopause; this nodularity is maximal before the periods. At the menopause the nodularity becomes less, and more fat is deposited. The classical signs of malignancy are: (1) adherence of the lump to the skin or to pectoralis major, (2) enlarged nodes in the axilla, and (3) 'peau d'orange'. The absence of these signs does NOT exclude carcinoma. Their presence increases the chances of it, but they are not confirmatory, because they can also be caused by tuberculosis, or fat necrosis, etc. If you are not sure if she has a lump or not, examine her in 2 weeks time, at the opposite phase of her menstrual cycle. Lumpi ness of the breast varies with the menstrual cycle. DIAGNOSING CYSTS IN THE BREAST If a lump is deep and spherical in all directions, it is probably a cyst; it mayor may not be fluctuant, and it can be benign or malignant. Cysts and solid lumps can be difficult to distinguish. You may see any of the following cysts, but only the first two are common. A mature breast abscess (very common, 21.2) has obvious signs of inflammation, and usually occurs in one breast only, commonly during lactation. Fibroadenosis (also called fibrocystic disease, common) makes both breasts abnormally granular, usually with premenstrual pain and some tenderness. One or more of these granular areas may be sufficiently obvious to be palpable as a cyst. She is between 25 and 60, there is occasionally an association with malignancy, and there may be a clear discharge from her nipple; rarely, this is blood-stained. An intracystic papilliferous carcinoma (rare) presents as a cyst. Aspiration yields blood-stained fluid, and does not make the cyst disappear entirely. Carcinoma of the breast with colloid degeneration (rare), feels cystic. Aspiration yields only a little thick fluid, and does not make the cyst disappear. Serocystic disease (cystadenoma phylloides, rare) is a rapidly growing benign giant fibroadenoma, which becomes partly necrotic and fluctuant. The skin over it may ulcerate, but is not inflitrated. A galactocele (uncommon) is a residual milk-containing cyst, the contents of which may solidify. Hydatid disease (not uncommon in endemic areas, 31.13). Look for cysts elsewhere, especially in the liver. DIAGNOSING SOLID LUMPS IN THE BREAST A developing breast abscess (common, see above). An abscess modified by antibiotics (an 'antibioma', common) is the result of treating an abscess with antibiotics, and not draining it. The lump is usually tender, but not always so. She may have tender axillary nodes and 'peau d'orange'. A fibroadenoma, (common) is a smooth, well-defined, solitary, and usually painless lump 2 to 5 cm in diameter (but which may be much larger), that moves freely in the breast (a 'breast mouse'). From its hardness such a lump could equally well be a carcinoma; mobility is the important sign, so is lobulation. There are two histological types, a common pericanalicular type, and a less common intracanalicular one. Be careful to distinguish a fibroadenoma, which is an isolated lump, from an area of nodularity due to fibroadenosis, which is a different disease. She is between 15 and 40, and usually between 18 and 25. Tuberculosis of the breast, (uncommon) is less often seen than tuberculosis of the axillary lymph nodes (31.4), and closely resembles carcinoma. Suspect tuberculosis if a lump is tender or there is a sinus. The mass is painless, and may be attached to her skin or the muscles of her chest wall. Look for signs of tuberculosis elsewhere. Biopsy the mass or her axillary nodes. If you cut across a tubercu lous node, you wi II see areas of caseation. Give the standard tuberculosis treatment. If she has a discharging sinus, you may have to admit her. There is no need for a mastectomy. CAUTION! In areas where tuberculosis is common, don't forget the possibility that it it may infect the breast or the axillary nodes. A giant fibroadenoma (uncommon), presents as a large breast filled with a large, deeply lying, hard, smooth, lumpy, mass (21.50). It it is untreated it may fungate as in Fig. 21-3. She is usually between 35 and 45. A neurofibroma (rare) feels hard, like a fibroadenoma, but may be soft, and may be one of many similar tumours elsewhere. A lipoma (uncommon) feels like breast tissue, but has an indistinct outline separating it from the surrounding normal breast. An intraduct adenoma (fairly common), or an intraduct carcinoma (less common). A carcinoma is more often palpable than an an adenoma. Both present as a discharge from the nipple, which is usually serous, but may be dark or blood-stained. The prognosis after limited removal is good. A carcinoma, may be schirrhous or medullary (both common). She has a hard, fixed mass with the criteria of malignancy listed above. Mastitis carcinomatosa (rare) is a highly malignant form of carcinoma seen during pregnancy. It is more generalized, and more like inflammation, or Burkitt's lymphoma, than the hard, fixed mass of a typical carcinoma. Burkitt's tumour(only seen in endemic areas, and uncommon even there) is usually bilateral. She is between the ages of 14 and 25. It may simulate mastitis carcinomatosa, but is not particularly associated with pregnancy. Her skin is stretched, and may ulcerate; she usually has other tumours elsewhere. Other possibilities include an organizing haematoma (fairly common), and fat necrosis (uncommon). MANAGING CYSTS IN THE BREAST If you think a mass is a cyst, proceed as follows. First, exclude hydatid cysts (if yours is an endemic area), by looking for lumps that might be hydatid cysts elsewhere in her body. Aspirate the cyst with a wide bore needle. If the fluid you aspirate is blood-stained, explore and biopsy the lump. If the lump remains after you have aspirated it, operate to remove the lump completely, unless it is very large, and send tissue for histology. If the fluid is clear and the lump disappears, as is usual in fibroadenosis (the commonest cause), no further treatment is necessary. Try to see her regularly. If the cyst appears again, or other cysts appear, aspirate again. If at any time lumps do not disappear, remove them as immediately above. MANAGING SOLID LUMPS IN THE BREAST Consider all lumps as malignant, until you are sure they are benign. Biopsy or excise solid lumps and send tissue for histology. The future management of the patient depends on the result. CAUTION! Excision of the entire lump for histological examination should be the general rule. The only occasional exception to this rule, is the lump which is 'almost certain to be benign', for example, it has all the features which suggest a fibroadenoma. If the patient is highly reliable, and does not want her lump removed, you can measure it, and see her every two weeks at first and later monthly, measuring it each time. If it enlarges or changes its character, remove it. Leaving such a lump should be the exception. You can remove most fibroadenomata through a THE PATHOLOGY OFA FIBROADENOMA Fig. 21-4 THE PATHOLOGY OF A FIBROADENOMA. A, the tumour is attached to the capsule by a stalk carrying its blood supply. Somoetimes the tumour extends into the capsule near the stalk. B, remove a superficial fibroadenoma by incising directly over it. Ifit is deeper, a submammary incision may be best. After Rob C and Smith R, 'Operative Surgery: Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley. periareolar incision, with a good cosmetic result if the lump is small. If it is an obvious fibroadenoma by the criteria above, shell it out without removing any normal breast tissue round it, and send part of the specimen for histology. If she has carcinoma of her breast, see Section 21.4. If she has a lump and a discharge from her nipple, her prognosis is better, because it is more likely to be a duct adenoma or carcinoma. Excise the duct involved (21.5) and her prognosis will be good. If you suspect that she has Burkitt's lymphoma of her breast, take a needle biopsy, stain a slide preparation, and interpret it yourself as in Fig. 32-3. Or, less satisfactorily, send a biopsy. If you are not confident that you can interpret a slide preparation, do both; excise the lump, make a slide from it, and send the biopsy for histology. If the tumour is large and ulcerating, excise it, and graft her exposed pectoralis major. If Burkitt's iymphoma is likely and histology slow, start chemotherapy immediately. MANAGING A DISCHARGE FROM THE NIPPLE This can be: (1) The normal active breasts of pregnancy (common). Colostrum can be discharged from the 16th week of pregnancy, and even earlier in multigravidae. (2) The normal usually milky discharge after lactation stops (fairly common). This may persist for months and occasionally years, especially if lactation is prolonged. (3) The discharge associated with fibroadenosis (uncommon). (4) The discharge associated with periductal mastitis (plasma cell mastitis, uncommon). (5) The clear, or less often blood-stained discharge, due to an intraduct adenoma (fairly common) or carcinoma (uncommon). Discharge is more serious if it comes from one duct rather than from many, if it is bloody, or if it is associated with a lump. At the start of the examination, don't palpate the her breast in the normal way, because this may squeeze out any secretion which has accumulated, and you want to see exactly where it is coming from. Instead, ask her to lie back. Gently wipe her nipple clean. Then, press with one finger 3 cm distal to her areola, and move it towards her nipple. Start at 'one o'clock' and move progressively all round her breast to the '12 o'clock' position. If there is any discharge, wipe it away and note its position. Then examine her breast in the usual way. If she is pregnant, and the fluid is clear and comes from many ducts in both breasts, reassure her. If both breasts continue to discharge milky fluid from many ducts, even years after lactation has stopped, reassure her. If she has fibroadenosis, the retention cysts it causes may occasionally cause a disharge from one breast, seldom both. Aspirate the cyst if she has one. If it does not disappear, or if the fluid is blood-stained, do an excision biopsy. If she has a watery, or bloody, or dark discharge from one duct, usually without a lump, she probably has an intraduct adenoma. If she has a lump, it is more likely to be a carcinoma; even so, her prognosis is good. Excise the lump with the duct (21.5). If she has a recurrent discharge from several points on her nipple, watery or viscid, green, white, black or occasionally bloody, suspect periductal mastitis (plasma cell mastitis, rare). This can also present as a hard, tender swelling with redness of the overlying skin, which you can confuse with an acute breast abscess, or a rapidly growing carcinoma. It may regress spontaneously. MANAGING A SINUS OR FISTULA IN THE BREAST A sinus or fistula may discharge milk, or a non-specific fluid. A milk fistula can follow a breast abscess (fairly common), or village surgery (fairly common in some communities), or tuberculosis of the breast (uncommon). Or it can complicate a carcinomatous ulcer. Other possibilities besides those below are a foreign body, and fungi. If she has a milk fistula, and is or should be breast-feeding, try to improve or re-establish breast-feeding soon. Her fistula will probably heal. If it does not, it will probably do so when she stops breast-feeding at the normal time. CAUTION! A milk fistula is not an indication to stop breastfeeding. Rather, it is an indication to re-establish breast-feeding soon, if it has stopped. NIPPLE DISEASES Chronic eczema, (uncommon) is bilateral. Clean her nipples frequently with soap and water. Apply Lassar's paste 1%, or hydrocortisone ointment 1%. Paget's disease of the nipple, (uncommon) is unilateral, and is a sign that that there is an underlying intraduct carcinoma. 'Peau d'orange' may develop around it. Excise all the area affected, with the underlying lump, including a margin of at least 2 cm of normal tissue horizontally and vertically. Close the wound as for a 'Iumpectomy' (21.5). DIFFICULTIES WITH BREAST DISEASES If she has evidence of ACUTE INFLAMMATION -a recent history, throbbing pain, and tenderness, don't wait for fluctuation. Treat her for a breast abscess, as in Section 21.2. Acute infection may be difficult to differentiate from mastitis carcinomatosa. If she is over 70 and has a SOFT FATTY LUMP, which feels as if it might be a lipoma, suspect that it is in fact a carcinoma, which can be as soft as a lipoma at this age. If BOTH HER BREASTS ARE ENLARGED, with pitting oedema, suspect some generalized disease, such as cirrhosis, the nephrotic syndrome, or heart failure. If she has ONE SWOLLEN PAINLESS BREAST, with PIT• TING OEDEMA and NO PALPABLE MASS, she may have:(1) Tuberculosis of her axillary nodes causing lymphoedema of her breast, or (2) non-specific inflammation of them. If she has tuberculosis, her affected breast is larger than the opposite one, is not tender or only slightly so, and almost always shows 'peau d'orange'. Her axillary nodes (usually the lateral pectoral group) are commonly matted together, and may be attached to underlying structures and her skin. She may also have a discharging sinus. Look for signs of tuberculosis elsewhere, especially enlarged nodes in her other axilla, her groins, and her abdomen. X-ray her chest, and do an ESR and a tuberculin test. See also Sections 31.4 and 31.6 and Chapter 29. This manifestation of tuberculosis affecting the breast via the axillary nodes is more common than tuberculosis of the breast itself. If she has SMALL FIBROTIC NODES IN HER AXILLA, not the typical enlarged matted tuberculous ones, and no signs of tuberculosis elsewhere, she may have chronic non-specific infection following repeated infection of her hand and arm, usually from wounds. Filariasis affecting her axillary nodes is another possibility (31.6). If a nipple is CHRONICALLY ULCERATED, suspect that this• is associated with an underlying duct carcinoma, unless she has a clear history of trauma. Biopsy it: there are also some rare causes such as syphilis and tuberculosis, etc. If anyone but a female over 10 years has a firm tender discoidSWELLING DEEPTOTHENIPPLE justlargerthanthe areola, and concentric with it, the condition is one of gynaecomastia. This is normal in infants of either sex, in boys near puberty, and in young men. In infants it is nearly always bilateral, and is sometimes complicated by mastitis. In young men it may be uni-or bilateral. Reassure all these patients. If both an adult MAN'S BREASTS ENLARGE, this is still gynaecomastia. If the clinical findings are not those of physiological gynaecomastia (see above), he probably needs investigation. He may have disease of his liver, testes, adrenals, or pituitary, or he may have leprosy, or have been treated with stilboestrol. Investigate him as best you can. Often, no cause can be found. If you decide to remove such breasts, do so as in Fig. 30-9. If one of A MAN'S BREASTS ENLARGES, he may have CARCINOMA OF THE MALE BREAST, or gynaecomastia; you can usually distinguish them clinically. If he has carcinoma treat him as if he were female. Excise it, together with some of the skin and the muscle underneath it. Because he has so little fatty tissue, the tumour infiltrates his skin and deeper tissues at an earlier stage, and his prognosis is worse. Orchidectomy usually produces a temporary remission. If he agrees, do the subcapsular operation. This leaves a small palpable 'testis', but even so it is not popularl (23.25). If ONE BREAST IS VERY MUCH LARGER THAN THE OTHER, but is otherwise normal, the patient may have GIANT HYPERTROPHY (uncommon). This is probably congenital, and may affect both breasts. Such breasts may enlarge more in the third decade, especially following pregnancy. 21.4 Carcinoma of the breast Carcinoma of the breast is very common in Caucasians, but is less common in Africans. Carcinoma of the African male breast is however not the rarity that it is in Europe. Carcinoma of the breast can occur at any age after 20 years, but is most common between 50 and 70, particularly in non-parous women and in women who started childbearing late; it is also common in the sisters of patients with the disease, and to a lesser extent in their daughters. Most carcinomas arise from glandular tissue. There are several types: (1) Schirrous carcinomas (75%) contain much connective tissue, and form hard lesions which cut like an unripe pear to produce a greyish cut surface which becomes concave. (2) Medullary (anaplastic) carcinomas (15%) contain less fibrous tissue and are softer. (3) Duct carcinomas (6%) are the least invasive, and present as a watery or blood-stained discharge from the nipple. Clinically, you cannot distinguish them from duct papillomas. (4) 'Inflammatory carcinoma' or 'mastitis carcinomatosa' (uncommon) is the most malignant type, and usually develops during pregnancy. Breast carcinomas form no capsule; they invade locally through the lymphatics, and spread widely through the bloodstream. A patient's prognosis is related to: (1) the stage at which treatment starts, (2) the number of nodes in her axilla that contain microscopic deposits, and (3), less significantly, the treatment she has. The stage at which the diagnosis is made is critical. Unfortunately, methods of self-examination, which are so effective in educated communities, are seldom applicable in poorly educated ones, in whom carcinoma commonly presents late. There is however one measure you can take — persuade your staff to examine their patient's breasts on every convenient opportunity. Carcinoma of the breast may present as a painless lump in the breast (80%), as enlargement of a breast, as ulceration, or as a discharge from the nipple, which is usually but not always bloodstained. Treatment is mainly surgical and is controversial-the radical and conservative schools do not agree, but the conservatives are gaining ground. As in any other part of the body, surgery can only cure carcinoma of the breast, if it is local and has not spread elsewhere. If radiotherapy is available (unusual in much of the developing world), it is the preferred treatment for axillary nodes. No known drug is curative, although the regimes below do give short remissions. Many patients present late with foul, stinking ulcers. A mastectomy at this stage, if it is possible (the growth may be fixed to the deep structures and make it impossible) relieves a patient's suffering, and makes her last months more bearable, but only if you can remove the tumour with a margin of normal skin all round it and still close the wound. CARCINOMA OF THE BREAST Here we assume that a patient has a lump in her breast, which you think is probably malignant by the criteria in the previous section. STAGING and PROGNOSIS. Here is the Manchester system of staging. The prognosis of scirrhous and medullary carcinoma is the same. Duct carcinoma has the best prognosis, even after the excision of an entire duct system, and mastitis carcinomatosa the worst. Stage One The growth is confined to her breast, and is not adherent to her pectoral muscles or to her chest wall. There are no enlarged nodes in her axilla. Adherence to the skin, or ulceration through it, does not affect staging, if it is smaller than the tumour. 68% of all patients survive 5 years, and 54% 10 years. Stage Two As for stage One, but there are now mobile nodes in her axilla. 60% of patients survive 5 years and 40% 10 years. Stage Three There is skin involvement which is larger than the tumour, but it is still limited to her breast. If any axillary nodes are palpable, they are still mobile. Or the tumour is fixed to her pectoral muscle, but not to her chest wall. Or it is fixed to both. 15% of patients survive 5 years and 4% 10 years. Stage Four She has distant metastases, either lymphatic, or blood-borne. These include infiltration of the skin beyond her breast, fixed nodes in her axilla, palpable nodes in her supraclavicular fossae, involvement of her other breast; or deposits in her bones, liver, or lungs (unusual). 4% of patients survive 5 years and 4% 10 years. On microscopic examination the axillary nodes are involved in 10% of patients in Stage One, although they may not be obvious for 20 years. Sadly, most patients in the developing world present in stages Three and Four. In Stages One and Two, a patient's prognosis depends on the stage of the disease, and where the primary tumour is in her breast. Tumours in the lateral half of the breast have a better prognosis. If the tumour is in the lateral half of her breast, and her axillary nodes are not involved, there is a 90% chance that she can be cured surgically. If they are involved, she has only a 50% chance of surviving 5 years. There is a 20% chance that it will recur locally. If it is in the medial half of her breast (less common), her prognosis is worse, because it is more likely to spread to her internal mammary nodes. THE MANAGEMENT OF CARCINOMA OF THE BREAST STAGE ON E. Do a 'Iumpectomy' (21.5). Excise 2 cm of normal breast round the lump, and send tissue for histology. No further treatment is needed, whether or not the report confirms carcinoma. INCISIONS FOR LUMPS IN THE BREAST Fig. 21-5 INCISIONS FOR REMOVING WMPS FROM THE BREAST. A,ifthelumpiswithin5cmofthethenipple, makeaperiareolarincision, not larger than half the circumference of the areola. Some scratches across the site of the incision before you make it will help you to align its edges. B, ifthe lump is further away make a curved circumferential incision over it, parallel to the areola. C, if the lump is deep in the breast, you may be able to use a submammary incision. D, slant a mastectomy incision obliquely towards the axilla. E, ifyour histology services are good enough tojustify taking a biopsy, make a radial incision within the area of a possible later mastectomy, so that you can excise the scar. Ifeither your histological services or the patient are unreliable, don't take a biopsy and then hope to do another operation later. STAGE TWO. Management depends on whether• or not histology is available without undue delay. If histology is available, first do a biopsy, and then proceed with one of the following operations as soon as the result is available. You have three choices. You can do: (1) A 'Iumpectomy' (see below) plus dissection of the axilla preserving pectoralis major. (2) A simple mastectomy plus dissection of the axilla preserving pectoralis major. (3) A 'conservative radical mastectomy' (Patey's operation). (4) Lumpectomy or simple mastectomy combined with radiotherapy to the axilla, if it is available. This is the best because it is least mutilating. If radiotherapy is not available, Patey's operation is recommended. CAUTION! For Stage Two, a 'Iumpectomy', or simple mastectomy without removing the axillary nodes, is not considered adequate; but it may be all you can do if you are unskilled. We have only described Patey's operation, but operation (2) above is almost the same. See Section 21.5 If histology is not available, or is only available after undue delay, proceed with one of the above definitive operations immediately. STAGES THREE AND FOUR, Surgery is only palliative, and may not be indicated if the metastases are worse than the primary. Aim to: (1) Prevent the tumour ulcerating through the skin. (2) Remove the primary in toto with, if possible, a margin of 2 cm of surrounding breast. Excise as much breast tissue as is necessary to do this. Usually, only a simple mastectomy is required, but you may need to remove part of her pectoralis major muscle. Leave the nodes in her axilla. The only indication for removing them is when they might ulcerate (unusual). This is only possible when they are mobile. Local removal will make life more bearable. Consider combining it with hormone therapy, which is cheaper and much easier than chemotherapy. MASTITIS CARCINOMATOSA may develop if a patient is pregnant. Try to distinguish it from an inflammatory mass by needle aspiration, and from Burkitt's lymphoma (in endemic areas) by needle cytology (32-3). Do the appropriate operation for the stage of the lesion. Anything you can do will probably only be palliative. Neither abortion nor subsequent pregnancies alter the prognosis. HORMONAL AND CYTOTOXIC TREATMENT FOR BREAST CANCER BILATERAL OOPHORECTOMY may help a premenopausal patient with metastases, especially in bone. It produces remission rates (usually partial) of 20% to 40% in premenopausal patients for up to 7 years, but is unpopular in some cornmuinities in the developing world. Length of life is not improved. OESTROGENS, Ethinyl oestradiol in a dose of 1 mg/day is useful for postmenopausal patients, and produces some symptomatic improvement in most patients, especially if they have pain from bony metastases. Or, give her stilboestrol 10 to 20 mg daily in divided doses. A PROGESTAGEN such as medroxyprogesterone acetate is a possible alternative, if she is postmenopausal. TAMOXI FEN is a non-steroid oestrogen antagonist which competes with oestrogen for receptor sites on the tumour cells, and has few side effects. Give 10 mg twice daily initially, and continue it indefinitely. Only some tumours are oestrogenreceptor-positive, and only a sophisticated laboratory can identify those that are. Tamoxifen causes partial remissions in postmenopausal patients. The remission rate 0to 5years after the menopause is 14%, 5 to 10 years after 30%, and> 10 years after 37%. Tamoxifen has been expensive, but is now (1988) much cheaper from secondary sources. CYTOTOXIC DRUGS produce remissions of 5 to 12 months in 50% of cases, especially in premenopausal patients with soft tissue lesions rather than bony metastases, but often with considerable toxicity. Single-dose regimes are not very effective. If drugs are short, carcinoma of the breast has a low priority; keep them for Burkitt's lymphoma and nephrobastoma. If you decide to use them, here are two possible regimes- Use the 'CMF' regime. Give her cyclophosphamide 100 mg/m2 by mouth daiIy for 14 days. Give her methotrexate 30 mg/m2 intravenously on days 1 and 8. Give her 5-fluorouracil 500 mg/m2 intravenously on days 1 and 8. Repeat the course 28 days after starting for up to a year if she responds. Stop if there is no response. Alternatively, give her doxorubicin ('Adriamycin') 60 mg/m2 every 3 weeks or 20 mg/m2 weekly to a cumulative maximum dose of 600 mg/m2. This simple regime is effective in a high proportion of cases, but will make her lose her hair. 21.5 Simpler operations for tumours of the breast If a patient has a carcinoma, or a suspicious lump in her breast, you have a choice of 5 operations: (1) You can 'shell out' a suspected fibroadenoma from the breast tissue around it. (2) You can do an excision biopsy or 'lumpectomy' to remove the mass and 2 cm of normal breast around it. (3) You can do a simple mastectomy. (4) You can do Patey's modified radical mastectomy as described in the next section. (5) You can excise an intraduct carcinoma. In operations (1) and (2) you do not remove the nipple or any skin, in (3) and (4) you always do. In (5) you remove some skin but leave the nipple. Dissection of the axilla is only described here as part of Patey's operation. There are two operations to avoid. (1) Ifeither your histological services or the patient are unreliable, don't take a biopsy, and then hope to do another operation later. She may not return, the report may be lost, and there will be too long an interval between the biopsy and the definitive operation. (2) Don't do a full radical mastectomy-it is mutilating and has no advantages over the modified radical operation described here. SIMPLER BREAST OPERATIONS 'SHELLING OUT' A LUMP INDICATIONS. This is only indicated if you suspect a fibroadenoma. METHOD. Proceed exactly as for lumpectomy except that you should shell out the mass without removing 2 cm of normal breast around it. 'SHELLING OUT' AND 'LUMPECTOMY' 'Shelling out' 'Lumpectomy' Fig 21•6 'SHELLING OUT' AND 'LUMPECTOMY' for the removal of a fibroadenoma. A, B, and C, you may be able to shell out a fibroadenoma through a small incision with minimal disturbance to the surrounding tissue. D, E, and F, you may have to expose the lesion, and remove it with a small part ofthe surrounding breast (lumpectomy). After Rob C and Smith R, 'Operative Surgery' Vol. 1 (2nd edn), (Butterworth) with the kind permission of Hugh Dudley. 'LUMPECTOMY' FOR A MASS IN THE BREAST INDICATIONS. (1) Any suspicious lump less than 5 cm in diameter. (2) A lump of unknown nature more than 5 cm in diameter. ANAESTHESIA. Ketamine (A 8.1) or general anaesthesia. INCISION. If you are removing a fibroadenoma from a young woman, try not to scar her breast or to compromise future lactation. Use a periareolar, or circumferential (less satisfactory), or submammary incision (21-5). If these are difficult, use any incision which will give good exposure and allow you to remove the lump. If you make a periareolar incision, you can remove a lump up to 5 cm or even 8 cm from the nipple. Gently dissect radially through the patient's breast from her areola, in line with the ducts. If you make an inframammary incision and approach the lump from the back, this will be less easy than removing it through a periareolar or circumferential incision. Use it for deep inferiorly placed lumps. Cut round the infra-lateral quadrant of her breast. In Caucasians and most Asians the crease under it usually forms a pigmented line. Hold her breast up while you make your incision in this line, and free it from her pectoral fascia. Continue to hold it up while you remove the lump from the back. Incise the posterior surface of her breast, until you have exposed the lump. Grasp it with forceps, and then free it from its bed with a scalpel or curved scissors. Remove it with a margin of at least 2 cm of macroscopically normal tissue. If an inframammary incision is too difficult, make a circumferential one directly over the lump. This may be necessary, but produces an obvious scar. It will however be less obvious than a radial one. With all incisions, use a sharp knife. If you suspect malignancy, excise the lump with a margin ofat least 2 cm ofnormal breast. Otherwise (as in a fibroadenoma) shell it out. If necessary, remove the lump with an elliptical segment of breast tissue, with its long axis placed radially. Bleeding is not usually much of a problem. If it is difficult to control immediately, pack the wound with swabs, apply pressure for 5 to 10 minutes, remove the swabs, and then either transfix and tie the bleeding vessels, or control them with diathermy. Close the cavity with interrupted sutures of plain catgut on a half-circle needle. If the cavity is too large to be completely obliterated by sutures, consider inserting a drain (some surgeons never insert one). Close her subcutaneous tissue with more interrupted sutures, and her skin with 3/0 or 4/0 monofilament. Postoperatively, apply a tight binder (uncomfortable), or a pressure dressing of adhesive strapping (better). SIMPLE MASTECTOMY INDICATIONS. A lump which is known or suspected to be malignant, and which is too large to remove by lumpectomy. CONTRAINDICATIONS. An uncertain diagnosis-never remove a whole breast when the diagnosis is not proven histologically, and the lump can be removed by lumpectomy (with a 2 cm margin of normal breast). If you don't know the diagnosis, do a lumpectomy. ANAESTH ESIA. Anaesthetize the patient as above. If the mass is ulcerated, suture some gauze squares to it after she is anaesthetized, to minimize contamination. INCISION. Make an oblique incision from the tail of the her breast superolaterally to its inferomedial margin. Ask your assistant to stretch her skin as you cut. Excise an ellipse of skin to include her nipple. Make it wide enough to let you dissect her breast adequately, and yet not so wide as to make closure difficult. Control bleeding by asking your assistant to press firmly with gauze as you cut. Dissect back the superomedial and inferolateral flaps, in the plane between her subcutaneous fat (usually 1 to 2 cm thick), and the fat of her breast. Continue the dissection in all directions to the periphery of her breast, where you will meet her pectoralis major muscle. Dissect her breast off this muscle (usually with a knife), clamping bleeding points as you proceed, until you have removed it in toto with the ellipse of skin. CAUTION! (1) Don't make the skin flaps too thin, or open up tissue planes more than is necessary. The flaps should be at least 1cm thick. (2) Don't remove her pectoral fascia, or muscle, unless the tumour is sticking to it. (3) Make the flaps of even thickness. Then enter her axilla, but only far enough to remove the axillary tail of her breast. The tail only extends a short way into the axilla. If the tumour is fixed to her pectoral muscle, remove part of it with her breast. You can, if necessary, remove most of it. But if you dissect it along her clavicle, be careful not to damage the vessels deep to the muscle. Remember that this is a Stage Three tumour, and you are not expecting a cure, so don't attempt anything too difficult. Now control bleeding points by diathermy or tie them with 2/0 plain catgut. Irrigate the wound with warm saline before you close it. Remove any redundant skin, so that the edges SIMPLE MASTECTOMY Fig. 21-7 SIMPLE MASTEClOMY. A, make an oblique elliptical incision, centred over the patient's nipple, from its superolateral to its inferomedial margin. B, dissect superolateral and inferomedial flaps. C, continue dissection in all directions to the periphery of her breast. D, dissect it off her pectoralis major. E, close. the wound with a drain. A suction drain (preferably 'Redivac') as shown for Patey's mastectomy would be better than the corrugated rubber drain shown here. After Rob C and Smith R, 'Operative Surgery', Vol. 1 (2nd edn), (Buttenvorth), with the kind permission of Hugh Dudley. of the incision come together cleanly. If you cannot close the wound completely, cover the bare area with a split skin graft (57.2). Insert a suction drain inferolateral to the incision. A 'Redivac' tube and reusable suction bottle are best. Or use a catheter with extra holes connected to a suction bottle, or, less satisfactori Iy, to a drai nage bag. Close her wound with plain catgut for the fatty layer, and 2/0 interrupted monofilament sutures for the skin. POSTOPERATIVELY, cover her breast with layers of gauze and cotton wool, and hold them firmly in place with adhesive strapping. Apply a pressure dressing for 3 or 4 days. Remove the drain when no more blood or serous fluid comes, usually at 3 to 7 days. Remove the stitches after 7 to 10 days, the alternate ones first. Let her use her arm as much as she wishes. Encourage active movement from the 4th day. EXCISING A DUCT PAPILLOMA OR CARCINOMA Aim to excise a single duct system with its surrounding tissue. Try to make sure that neither the patient, nor anyone else, squeezes her breast during the 2 or 3 days before you do so in the theatre. Under general anaesthesia, find the orifice of the affected duct by squeezing the secretion out of it. You may be able to feel the lesion under her areola (see the method for examining a breast for this condition in Section 21.3). Pass a fine probe or a hypodermic needle with a blunt end along the duct. Ask your assistant to hold this, while you excise an oval of skin and breast tissue with the duct and the lesion. Make sure that you excise the probe with a margin of at least 2 cm of macroscopically normal tissue horizontally and vertically all AN INTRADUCT PAPILLOMA A press all round the areola \\\\\1\\1\\\\\ \\\\\\\\\\\\\",,,, B c pass a probe down the duct Fig. 21-8 EXCISING AN INTRADUCT PAPILWMA. A, carefully palpate all round the breast to find out which segment the discharge is coming from. B, a lesion in the wall ofa duct which might equally well be a duct papilloma or a carcinoma. C, pass a fine probe down the duct, and excise it with some of the surrounding tissue. excise the duct EXCISING A GIANT FIBROADENOMA Fig. 21-9 EXCISING A GIANT FIBROADENOMA. If the mass only occupies part ofthe breast, you may be able to shell it out like this. Otherwise, you may have to do a simple mastectomy. After Rob C and Smith R, 'Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley. round the duct, except at the nipple. Suture the deeper layers with plain 2/0 catgut to obliterate the dead space. Close her skin with 2/0 or 3/0 monofilament. There is no need for a drain. If haemostasis is not good (unusual), apply a pressure dressing. Send the specimen for histology. Remove alternate stitches at 7 days. At the first review, if the pathologist reports a papilloma (75 0/0 chance), reassure her. If he reports a carcinoma (15°10), follow her up carefully each month for at least 6 months. These carcinomas are low-grade, so the operation itself may be sufficient. DIFFICULTIES WITH TUMOURS OF THE BREAST If she presents with a GIANT FIBROADENOMA, simple removal may not be practical, and you may have to do a a simple mastectomy. If it only occupies part of the breast, you may be able to shell it out. If you preserve normal breast tissue where you can, her breast may retain its normal shape afterwards. If a MASS FORMS IN THE SCAR after you have done a lumpectomy or mastectomy for carcinoma, consider the possibility of a local excision. 21.6 Patey's operation for carcinoma of the breast, modified to remove pectoralis minor The traditional radical mastectomy (Haagenson, Stiles, and others) removes both pectoralis major and minor. Removing pectoralis major is mutilating, and has not been shown to produce any more survivors than operations which leave it, such as Patey's. In its original form Patey's operation removes pectoralis minor also. This is is easier than preserving it, because it allows you to remove all the tissues containing the lymph nodes in the axilla 'en bloc', up to the axillary vessels and the brachial plexus. Patey's operation isfor the careful caring operator, who cannot refer his patient. Its aim is to try to remove her breast, and with it the triangular mass offibrofatty tissue and lymph nodes in her axilla which is bounded by serratus anterior medially, latissimus dorsi posteriorly and laterally, by coracobrachialis above, and by the axillary apex superomedially. During the operation your assistant will have to retract pectoralis major forwards, so that you 346 ANATOMY FOR MASTECTOMY Fig. 21-10 ANATOMY FOR A MODIFICATION OF PATEY'S OPERATION. A, the empty axilla to show its muscles, as ifits contents were absent. B, pectoralis major is shown cut away to reveal the structures under it. In reality it is retained. The key to structures in this and later figures is: 1, pectoralis major (retained in this operation). 2, pectoralis minor (removed in this operation). 3, serratus anterior. 4, subscapularis. 5, latissimus dorsi. 6, biceps. 7, triceps. 8, teres major. 9, coracobrachialis. 10, the axillary space. 11, the coracoid process. 12, the nerve to serratus anterior. 13, the nerve to latissimus dorsi. 14, the lateral pectoral nerve. 15, After Rob C and Smith R, 'Operative Surgery', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley. can see under it. The key to dissecting the axilla is to expose the anterior edgeoflatissimusdorsi, andtofindtheplanejustmedialto it, which contains the subscapular vessels and the nerve to this muscle. Having done this, you will have to remove all pectoralis minor, and the clavipectoral fascia in continuity with it. The clavipectoral fascia is a sheet of tissue which extends from the apex of the axilla, where it is attached to the clavicle, to the base of the axilla, where it is continuous with the axillary fascia. It encloses pectoralis minor. Aim to remove it completely, together with the fat and lymph nodes that are associated with it. PATEY'S OPERATION Refer the patient if you can; if not proceed as follows. ANAESTHESIA. General anaesthesia. Have two units of blood cross-matched for her. CAUTION! For the methods of controlling bleeding, see the previous section. EOUIPMENT. A general set (4.12). A large right-angled retractor. At least 24 Spencer Wells or similar haemostats. Find two competent assistants. PREPARATION. Sit her up a little, prepare and paint her back and flank on the affected side, and then let her lie back on a plastic sheet covered with a sterile towel, as in A, and B, Fig. 21-11. If you don't do this, the back of her flank will not remain sterile during the operation. Drape her arm so that you can flex and extend it when necessary, without disturbing the drapes. You may need to cover a bare area, so prepare her thigh for skin grafting (57.2). A sandbag behind her lower thigh will make cutting the graft easier (optional). INCISION, Plan the incision so that the tumour is in the middle of an island of skin, and at least 4 cm away from any palpable edge of the tumour. Make an oblique incision from her coracoid process, which you will be able to feel 2.5 cm inferior to the junction between the middle and outer thirds of her clavicle, to a point about 5 cm superolateral to the xiphoid process of her sternum. Bring the lateral edge of the ellipse well medial to the outer border of her pectoralis major (the anterioraxilIaryfold). Don'textend itdown herarm oroverthe front of her shoulder. RAISE TWO FLAPS as you would if you were doing a simple PATEY'S A MASTECTOMYONE Fig. 21-11 PATEY'S MASTECTOMY-ONE. A, and B, draping the patient. Unless you prepare and drape her like this, the back ofher flank will not remain sterile during the operation. C, plan the incision, so that the tumour is in the middle ofan island ofskin, and at least 4 cm away from any palpable edge ofthe tumour. D, carry the inferior flap back to just beyond the anterior border ofher latissimus dorsi. E, dissect the tissues superficial (not deep) to latissimus dorsi for 5 cm. For a key to. numbered structures see caption to Fig. 21-10. After Rob C and Smith R, 'Operative Surgery', Vo/. 1 (2nd edn), (Butterworth), with the kindpermission ofHugh Dudley. mastectomy (21.5). Start with the inferolateral flap, and carry this back to 5 cm beyond the anterior border of her latissimus dorsi. Find the nerve to this muscle, which enters it with her subscapular vessels on its deep surface, near its anterior border. If you have placed your flap correctly, you will encounter latissimus dorsi as in E, Fig. 21-11. CAUTION! If you dissect the inferolateral flap too deep you will: (1) make it too thick, (2) leave pieces of breast or lymph nodes in it, (3) endanger the nerve to latissimus dorsi, and (4) find the accompanying subscapular vessels a nuisance. Now dissect the superomedial flap to reach the edge of her breast. Dissect this from the underlying muscle, as described in Section 21.5 for for simple mastectomy. TURN HER BREAST LATERALLY starting from the point where the flaps join inferomedially. Begin over her thoracic cage near the root of her xiphisternum. Dissect her breast away from her pectoralis major, clamping the vessels entering its deep surface as you progress. You will now have turned her whole breast over on itself to leave it lying laterally (F). ENTER HER AXILLA to mobilize the axillary tail of her breast, by dissecting along her chest wall posterior to pectoralis major. Ask your assistant to lift her pectoralis major to make this easier. You should now see the edge of her pectoralis minor. Dissect towards it. Separate its origin from her chest wall-it arises from ribs 3,4, and 5 and from the intervening intercostal spaces. Dissect her clavipectoral fascia from her thoracic wall, working superomedially to reach the apex of her axilla, where you will see the fascia carrying her axillary vessels, before they disappear under her clavicle. Your assistant will have to retract her pectoralis major well at this stage. A cutaneous nerve, the intercostobrachial, crosses through her axillary fat from the chest wall medially (T2), to supply the skin of her axilla and upper arm. You can sacrifice this. While you are dissecting away pectoralis minor, you will meet some of her lateral pectoral vesels. Clamp these and tie them with 2/0 multifilament, or coagulate them with diathermy. Now start dissecting her axilla, where you have exposed the edge of her latissimus dorsi. Find the nerve to this muscle, if you have not done so already, and preserve it. Dissect the tissues off the superficial surface of latissimus dorsi for about 3 cm. This will help when you come to close the wound. Now, start inferolaterally to dissect the contents of her axilla from latissimus dorsi laterally, and from serratus anterior covering her thoracic wall medially. CAUTION ! Preserve: (1) The nerve to latissimus dorsi as it crosses the posterior wall of her axiIla. (2) The nerve to serratus anterior, which lies on the surface of this mu'scle, on the medial wall of her axilla. Work superiorly along the anterior edge of latissimus dorsi, towards her axillary vessels (the vein lies inferomedial to the artery) and her associated brachial plexus. You should see the vein first; it is delicate and has several small branchesso be carefuI! Dissect the contents of her axilla away from her axillary vein along the line 'X' in G, Fig. 21-12. As you dissect medially along the vessels and nerves, continuing to expose the inferior and medial aspect of the vein, you will meet from lateral to medial: (1) Her subscapular artery and its two veins. Leave these if you can. (2) Her lateral pectoral artery. (3) Her acromiothoracic artery with four branches, two of which enter the field medially. (4) Her superior pectoral vessels. PATEY'S MASTECTOMYTWO H Fig. 21-12 PATEY'S MASTEClOMY-TWO. F, clear the whole of the patient's pectoralis major to its lateral edge. G, the entire contents ofher axilla, including her clavipectoral fascia, pectoralis minor, and her breast have been reflected laterally. The insertion ofher pectoralis minor into her coracoid process is about to be divided ('X'). H, pectoralis minor has been divided and her clavipectoral fascia is about to be removed. For clarity, the nerve trunks ofthe brachial plexus are not shown. I, the wound has been closed, and long tubular drains are in place. For a key to numbered structures see caption to Fig.21-10. Use blunt dissection to separate the fascia anteriorly and posteriorly. While you dissect medially, ask your assistant to lift up her pectoralis major more. Ask another asistant to lift her arm, which has been lying on its arm board. When you reach the apex of her axilla, you will be able to feel her first rib, and will meet the dissection you have done along her anterior chest wall. Now find the insertion of her pectoralis minor into her coracoid process. To reach it you will need sharp dissection with scissors along her axillary vessels. Divide its insertion near the bone (H). This will enable you to remove the contents of her axilla 'en bloc', including her pectoralis minor and her attached breast. DRAINING AND CLOSING THE WOUND. If possible insert suction drains (a reusable 'Redivac' bottle and tube is ideal). A two-ended drain is best. Insert two perforated tube drains through separate stab incisions in the inferolateal flap. Corrugated drains can be used, but increase the risk of infection. Starting at each end, use '0' monofilament to close the wound with simple interrupted sutures, spaced about 1 cm apart and passing through the skin 0.5 cm or less from its edge. Or, use a continuous blanket suture. Avoid mattress sutures, which leave an ugly scar. You should be able to close the wound using skin sutures only, unless she is very fat. If you cannot close the wound without tension, close its ends first. Then sew the edges of its middle part to pectoralis major, and apply a split skin graft (57.2) to the muscle bed. Place gauze over this graft, and hold it in place with 3 pairs of 'tie over sutures' (57-8) inserted through the skin edges. Applya pressure dressing for 3 or 4 days. Remove the drain when no fluid flows, usually at 4 to 7 days. Remove alternate stitches on the 9th day, and the others on the 10th day, or later if necessary. Start arm exercises on the 7th day, especially those for shoulder abduction, internal rotation (ask her to put her hand behind her lower back), and external rotation (ask her to put her hand on the back of her neck). DIFFICULTIES WITH PATEY'S OPERATION If you DAMAGE HER AXILLARY VEIN, clamp it above and below with arterial clamps, or with Spencer Wells forceps with rubber tube over their jaws. Sew up the hole with 4/0 or 5/0 multifilament silk or monofilament, not catgut. If you cannot repair the tear, tie her vein proximally and distalIy. This will usually only cause temporary ischaemia of her arm, because her cephalic vein is still intact. If SHE IS UNABLE TO PULL HER SHOULDER DOWN, you have damaged the nerve to her latissimus dorsi. This is not a great disability. If she has a WINGED SHOULDER, you have damaged the nerve to her serratus anterior. This looks unsightly. THE THYROID 21.7 The general method for thyroid The common surgical problem with the thyroid is a painless increase in its size, or the appearance in it of a painless mass. A painful thyroid is either due to haemorrhage (not uncommon in colloid goitre or carcinoma), or an abscess (rare in the developed world, and seen infrequently here, 5.10a). When a goitre or a mass needs surgery, the patient usually needs subtotal or total removal of his thyroid. This is not easy, and we have already given our reasons why you should refer the patients who need this done (21.1). There are however some ways in which you can help patients with surgical diseases of their thyroids. GENERAL METHOD FOR THE THYROID DIAGNOSIS. Note the patient's age, his (or more often her) sex, and where he lives. Simple and colloid goitres are common in females in the second and third decades, and in anyone who lives in an iodine-deficient area. How long has it been present? Has there been a sudden increase in the size of the mass in his neck? Is it painful? Does he have difficulty breathing or swallowing? Inspect his neck from in front, and feel it from in front and from behind. Give him a drink, and confirm that it moves up when he swallows (all thyroid swellings do this). Feel the size of its lobes and its isthmus; feel its surface and consistency, and listen for a bruit. IS HE HYPERTHYROID? You can diagnose moderate and severe thyrotoxicosis clinically. Minor degrees require measurement of his basal metabolism and/or hormone assays. Suggesting hyperthyroidism: Loss of weight? Tremor, especially of his outstretched arms and fingers? Sweating? Anxiety? Hyperactivity? Exophthalmos? Lid lag (his upper lid is slow to follow his globe when he looks downwards)? Palpitations? Tachycardia? Cardiac irregUlarities (flutter, fibrillation)? SOME THYROID B LESIONS ....... Fig. 21-13 SOME LESIONS OF THE THYROID. A, a patient with a non-toxic adenomatous mass in her thyroid gland. D, the mass removed at thyroidectomy. C, the smooth, soft, symmetrical goitre of puberty or pregnancy. D, the large, smooth firm symmetrical swelling ofa colloid goitre, thyrotoxicosis, or Hashimoto's disease. E, a large, nodular, firm, assymetrical goitre. F, the solitary nodule ofan adenoma, carcinoma, or cyst. G, congenital abnormalities of thyroid development. 1, the foramen caecum. 2, 3, and 4, positions for thyroglossal cysts. 5, the pyramidal lobe. 6, a mediastinal goitre. 7, the hyoid bone. 8, the thyroid cartilage. A, and B, after &wessman, Charles, 'Surgery and Clinical Pathology in the Tropics,' E and S Livingstone, with kind permission. Heart failure? His thyroid is usually enlarged, and mayor may not be nodular. You can often hear a bruit. SUDDEN ENLARGEMENT OF THE THYROID GLAND In order of frequency the causes are: (1) Bleeding into the cyst of a colloid goitre. This will make it painful initially, but the pain may have gone by the time he presents. (2) Increase in the size of the colloid cysts of a goitre (this is not really sudden). (3) Bleeding into a carcinoma. (4) A rapidly growing carcinoma. (5) Acute bacterial infection (5.10a). Refer him urgently. If dyspnoea is present, aspirate the haematoma or the abscess. If this does not relieve him (unusual) try tracheal intubation (A 13.2) or tracheostomy (52.2, difficult). A SOLITARY NODULE IN THE THYROID If he presents with a solitary nodule, first confirm that it is in his thyroid, and then feel carefully for other nodules. If there are other nodules he probably has a nodular colloid goitre, and he may perhaps be thyrotoxic (unusual). If it really is a solitary nodule, it is quite likely to be a papillary carcinoma (which has a good prognosis with radical surgery), or a follicular carcinoma (with a worse one). Refer him to an expert, who will explore his neck and do a subtotal, hemior total thyroidectomy, as required. If you have a quick and reliable histology service, consider needle biopsy. Even a good pathologist may have difficulty distinguishing normal thyroid tissue from a low-grade papillary carcinoma. He will however be able to recognize the nodule of a colloid goitre. CAUTION! (1) Enucleation is easy, but is not satisfactory because: (a) It does not remove a carcinoma completely. This is particularly important if it is papillary. (b) He may think he is cured, and not report back for radical surgery. (c) It makes a second operation more difficult. (2) Don't explore a solitary nodule unless you can do a thyroidectomy. If he is unable or unwilling to be referred, follow him up regularly, and measure the nodule. If it enlarges try to persuade him again to be seen by an expert. DON'T TRY 10 EXCISE A SOLITARY THYROID NODULE UNLESS YOU CAN DO A THYROIDEClOMY 21.8 Hyperthyroidism (thyrotoxicosis) This is much less common in most rural communities of the developing world than it is in the industrial world, but it is becoming more common in towns. Look for the signs listed above (21.7). HYPERTHYROIDISM MEDICAL TREATMENT is the first choice for all cases, except where the disease arises in the nodule of a pre-existing nodular goitre (toxic nodule). Unfortunately, the relapse rate after medical treatment is 50%. Admit the patient and give him: (1) Tabs propanolol 40 mg three times daily (or some other ß-blocker). Within 48 hours there should be a fall in his pulse rate, and a diminution of his tremor, anxiety, restlessness, heat intolerance, and sweating. If there is no response in 48 hours, increase the dose to 80 or even 160 mg four times daily. If necessary continue for 2 or 3 months. Or, use another beta blocker. CAUTION! (a) 40 mg of propanolol orally is only effective for about 6 hours. If he presented with severe hyperthyroidism, severe symptoms, or even a crisis may follow the omission of a single dose. Regular doses are especialy important just before and immediately after surgery. (b) Don't use propanolol for long-term treatment. (2) Tabs carbimazole 10 to 20 mg three times daily. Reduce this dose when his symptoms are controlled. He may experience symptomatic improvement in a week, but you may have to wait 3 to 6 weeks for an objective clinical response. Slowing of the pulse and weight-gain are the most reliable signs of improvement. When you judge him to be euthyroid reduce the dose to between 2.5 to 5 mg three times a day. Continue treatment for 18 months to 2 years if necessary. His hyperthyroidism may remit spontaneously, so that he needs no further treatment. Watch for the side effects of carbimazole (rashes etc.) If he relapses (>50% chance), advise surgery or a second course of medical treatment. The latter only succeeds in 25% of cases. SURGICAL TREATMENT. He should be euthyroid before surgery. If possible refer him untreated, so that the expert can assess his clinical state before treatment starts. If this is impractical, treat him with propanolol and carbimazole for 6-8 weeks before the expected date of the operation. Most surgeons give Lugol's iodine 1 ml daily for 10 days preoperativeIy to reduce vascularity. Beta blockers are continued up to the operation and for 10 days afterwards. CAUTION! It is dangerous to operate on thyrotoxic patients who have not had antithyroid drugs for 6-8 weeks preoperativeIy. Even then, postoperative thyrotoxic crises occur. Thyroidectomy is not an operation for the generalist! The recurrence of hyperthyroidism after a bilateral subtotal thyroidectomy is very unusual. However, 30% of patients become hypothyroid within 10 years and need I-thyroxine 100 to 200 micrograms daily. 21.9 Thyroglossal cysts A thyroglossal cyst is a smooth, painless, subcutaneous lump which usually lies on the thyroid cartilage just to one side of the midline (G, Fig. 21-13). These cysts occur in both sexes equally, usually between the ages of 15 and 40, and are formed from the epithelial pouch that gives rise to the thyroid gland. This runs from the junction between the anterior two-thirds and the posterior third of the tongue (the foramen caecum, 21-13), to the pyramidal lobe of the thyroid, just above the isthmus. Cysts sometimes occur within the pyramidal lobe, or in relation to the hyoid bone. Excision is usually not difficult. Occasionally, however, an extension of the cyst goes up to and through the hyoid bone, which may need to be divided, so refer the patient if you can. If you cannot refer him, proceed as follows. THYROGLOSSAL CYST ANAESTH ESIA. (1) General anaesthesia with intubation (A 13.1). (2) Intravenous ketamine (A 8.2). (3) Local anaesthesia (A 5.4). INCISION. Make a 6-8 cm transverse incision in a skin crease over the swelling. Separate the tissues between the patient's strap muscles in the midline longitudinally. If exposure is inadequate, divide these muscles transversely. Also divide the pretracheal fascia covering the cyst. Dissect it out with scissors. Close the wound in layers. Approximate his strap muscles with 3/0 plain catgut, and his skin with 3/0 or 4/0 monofilament. Remove the sutures on the 5th day. If an extension of the cyst extends up into his neck through his hyoid bone (uncommon), follow it upwards and divide his hyoid bone if necessary. No vital structures are in the way, and his divided hyoid does not need repair. If a remnant is left behind the cyst may recur. 21.10 Physiological goitre A physiological goitre presents as a uniform, smooth, painless swelling of the thyroid gland, mainly in girls and women between 15 and 25. It appears to be about equally common everywhere, and does not cause dyspnoea or dysphagia. It often resolves spontaneously as the period of maximal hormonal activity passes. 21.11 Colloid goitre Colloid goitres are worldwide, but are very common in areas of iodine deficiency (endemic goitre). They can be prevented by the administration of iodine to the entire community, which also prevents the other manifestations of endemic iodine deficiency (iodine embryopathy, etc.). Colloid goitres occur between the ages of 20 and 50, and affect women more than men. Large ones obstruct breathing by narrowing or displacing the trachea, and they may occasionally obstruct swallowing. Sometimes, they extend into the thorax. They can be 'simple', in which case they are larger and firmer than a normal thyroid and have a regular surface. More often they are nodular. Although the patient may complain of a single nodule, he usually has more than one, with one lobe ofhis thyroid much larger than the other. There is no bruit over the nodule unless it is a toxic (hyperthyroid) nodule. Treatment, when it is indicated, is surgical. One of the dangers of a colloid goitre is that bleeding into it may cause it to increase in size suddenly. COLLOID GOITRE If a colloid goitre is small, and is causing no obvious symptoms, surgery is not really necessary, and the indications for its removal are cosmetic. Discuss this with the patient in the light of the available surgical and anaesthetic skills and priorities. If he has dyspnoea or dysphagia, or the gland is large, sub total thyroidectomy is indicated, but is seldom urgent. If there has been a sudden increase due to haemorrhage (unusual) see above. 21.12 Tumours of the thyroid Adenoma It is doubtful whether a true adenoma of the thyroid exists, because it is difficult to differentiate histologically from a low-grade papillary carcinoma. Adenomas present as solitary nodules. In most communities the commonest nodules are colloid goitres. Carcinomas are seen occasionally everywhere, and vary from the very slow-growing to the very malignant. In Europe the frequency of the various types is as follows. (In Africa the follicular type is relatively more common.) Papillary carcinomas (70 %), are of low-grade malignancy, and present as a nodule with or without spread to the lymph glands of the neck. The histological appearances of a needle biopsy resemble those of a normal thyroid or an 'adenoma'. Refer the patient for total thyroidectomy and block dissection of his neck on one or both sides, which will probably cure him (5 year survivals 95% and 10 year survivals 90%). . Follicular carcinomas (20 %) spread to bone early, so that the first sign may be a bony secondary. He may have a lump or area of thyroid enlargement, or his thyroid may be clinically normal. If the disease is confined to his neck, refer him for a radical thyroidectomy, and a block dissection on one or both sides. If he has metastases to bone or other organs, there is little to be done. Radiotherapy often gives temporary improvement. About 5% of tumours take up radio-iodine, which is very effective. Follicular tumours range from low-grade to high-grade malignancy: (1) If he has a low-grade tumour with no metastases, he has an 86% chance of 10 year survival after radical thyroidectomy. (2) If he has metastases in his neck he has a 44% chance of survival. (3) If he has distant metastases, his prognosis is the same as for an anaplastic carcinoma. Medullary carcinomas (3-5 %) have a familial incidence, and are transmitted as a Mendelian dominant. They have a characteristic histological appearance, a poor prognosis, and may be part of a system of multiple endocrine tumours. Anaplastic carcinomas (5 %) mostly occur in elderly women, and are little helped by radiotherapy; radio-iodine is not taken up. 75% of patients are dead in two years. 21.13 Other problems with the thyroid You may see the following three non-neoplastic diseases of the thyroid. Apart from lymphocytic thyroiditis they are uncommon, and you may have to do a needle biopsy to distinguish them. OTHER THYROID PROBLEMS If a goitre is uniform and feels unusually FIRM and VERY WELL-DEFINED but is not particularly tender, consider the possibility of autoimmune lymphocytic thyroiditis (Hashimoto's disease, not uncommon). The patient is aged 20 to 70, and is usually about 50. Women are more commonly affected than men. Spontaneous resolution is usual but slow. Hypothyroidism often develops, and needs replacement therapy with I-thyroxine 100 to 200 micrograms daily. Prednisolone is of doubtful value. If a patient's thyroid has become uniformly enlarged, MODERATELY TENDER, and PAINFUL over some weeks or months, he may have subacute thyroiditis (de Quervain's disease, uncommon). This is a non-suppurative inflammation, sometimes with hyperthyroidism. The ESR is raised. It is selflimiting, but you can promote its resolution by giving him prednisolone 30 mg daily, until his pain and swelling subside. He has a 10% chance of becoming hypothyroid. If his thyroid becomes WOODY-HARD, is fixed to the surrounding tissues, and is either normal-sized or a little enlarged, suspect RIELEL'S THYROIDITIS (woody thyroiditis, rare). Distinguish this from malignant tumours.